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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530047
Report Date: 01/21/2026
Date Signed: 01/21/2026 12:43:37 PM

Document Has Been Signed on 01/21/2026 12:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BANYAN HOUSEFACILITY NUMBER:
365530047
ADMINISTRATOR/
DIRECTOR:		ESTELLE, VICKIFACILITY TYPE:
735
ADDRESS:18326 BANYAN AVETELEPHONE:
(909) 587-2431
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 6CENSUS: 5DATE:
01/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Norman Smith, House Manager, and Vickie Estelle, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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Licensing Program Analyst, LaVette Farlow, (LPA) arrived at the Banyan House, Adult Residential Facility unannounced to conduct an Annual Inspection. LPA introduced self and stated purpose of the visit. LPA met with House Manager, Norman Smith who granted LPA entry inside facility. Norman contacted Administrator, Vicki Estelle, who arrived later during the visit.

LPA was accompanied by Norman, to conduct a tour of the facility, inside and outside, and observed the following:

Facility: The Facility is approved for six (6) ambulatory adults, ages 18 -59. The current census is six (6). LPA observed that the facility is operating in the capacity and conditions approved by Community Care Licensing (CCL).

Physical Plant: LPA observed the facility to be maintained at a comfortable temperature. Interior and exterior pathways were free of clutter and obstructions. LPA tested the facility water and the temperature tested at 116.0 and 115.8 degrees. LPA observed 5 bedrooms and 3 bathrooms. One (1) room is for live in caregiver. Resident rooms each included appropriate lighting, seating, bed and linens and storage for residents in care. Various light sources such as lamps and night-lights were observed throughout the facility. Each bathroom included operable appliances, adequate amounts paper supplies, non-slip materials and handrails. LPA observed hygiene supplies, personal and linens are kept and secure in hallway closets. Additionally, LPA observed chemicals, tools sharps and resident medications were also kept secure in a hallway closet. Fire extinguishers, (2) were observed fully charged and last inspected August 18, 2025. LPA was informed the facility conducts fire and earthquake drills regularly. LPA found the records for the facility drill were documented.
***Continued on LIC809C***
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BANYAN HOUSE
FACILITY NUMBER: 365530047
VISIT DATE: 01/21/2026
NARRATIVE
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Food Service: LPA observed the facility's kitchen. LPA observed the facility had an sufficient amount of perishable and non-perishable food supply. LPA observed the facility's refrigerators and freezers to include food items such as milk, bread, fresh fruits and vegetable and beverages also sufficient in amounts for the number of clients in care. LPA observed the facility was equipped with emergency food supply in case of evacuation.

Care & Supervision: The facility has sufficient staff for the number of clients in care 24/7 care and supervision to include a live in caregiver.

Record Review and Resident/Staff Files: LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed two (2) client medications log and centrally stored medication sheet. LPA observed the logs were not maintained and with errors. The logs were missing medications and missing a ledger for each client. A deficiency cited. The client P&I was reviewed and appeared with errors the funds did not match the ledger. A Technical violation issued. LPA reviewed four (4) staff files for current CPR/First Aid Certification, Criminal Record Clearance, Health Screening and TB test, and training. LPA observed personnel records were maintained.

Administrative files: Facility Sketch/Disaster Plan, Emergency contact information, Ombudsman poster, Resident Rights, House Rules, Infection Control, Administrator Certificate, and facility license are posted in the hallway of the facility.

Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and secure in a hall closet. LPA reviewed the residents' medications list and compared it to the facility's Medication Administration Report (MARS). LPA observed several medications were not listed on the MARS, the medication log sheet was missing an initial, and the facility did not maintain a centrally stored medication log. Also, the medication were transferred to a separate container to be dispensed. Deficiencies cited.

Based on the information observations and review of records during this visit today one (1) technical violation and two (2) deficiencies were cited per Title 22, Division 6 of The California Code of Regulations. This report LIC809, LIC809C, LIC809D, and appeal rights were reviewed and a copy provided to House Manager, Norman Smith.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 01/21/2026 12:43 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/21/2026 at 11:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BANYAN HOUSE
FACILITY NUMBER: 365530047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(6)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (6) No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out 2 clients in care by not ensuring all prescription medication is maintained in it's original container and not transferred which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/01/2026
Plan of Correction
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The Licensee will ensure that all staff dispensing medication maintain the medication in it original container and medication is not prepared and stored for later dispensing. Licensee also agrees to complete a training with all staff by POC due 2/18/2026, and submit proof to LPA.
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 3 clients by not maintaining a centrally stored medication log. Also, 1 out of 2 client was missing an initial on the dispensed morning medication log which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2026
Plan of Correction
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Licensee agrees to update each client file to ensure all medication is listed on the centrally stored medication log and each medication dispensed is initialed. Licensee will complete a staff training on maintaining and storing and common medication error with all staff by POC due date 2/18/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2026


LIC809 (FAS) - (06/04)
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